“My findings of fact included the following:- 1”
Dated 1 Aug 2016, from the coroner for East London. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 26 Sep 2016. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated1 Aug 2016
- Deadline26 Sep 2016
- Published on judiciary.uk1 Aug 2016
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| North Middlesex University Hospital NHS Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.
— My findings of fact included the following:- 1. | was informed that the Trust policy in place in December 2014 required a patient presenting with a current attempt at self-harm and suspected drug use to be nursed in an observable area AND to be kept within eyesight at all times. The evidence revealed that Joshua was not kept within eyesight at all times. 2. The evidence revealed that it is common for patients to leave the North Middlesex A & E prior to psychiatric assessment. This was confirmed by the triage nurse in her oral evidence and also stated within the Root Cause Analysis Investigation Report of Barnet, Enfield and Haringey Mental Health NHS Trust. 3. The triage nurse who gave evidence during the course of the Inquest did not consider that it would be possible to make a patient to remain within the hospital for their own safety. She was unaware of the nurses holding power under Section 5.4 of the Mental Health Act. 4. The North Middlesex University Hospital NHS Trust did not consider this matter to fall within their criteria for a Serious Incident. No Serious Incident Investigation was carried out. 5. The consultant psychiatrist who gave evidence at the Inquest. Hearing confirmed that had Joshua been referred to him on the morning of the 1** December 2014, the presentation at that time would have resulted in him being admitted to hospital (with or without his consent).
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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